Billing patient transport to German health insurers: from prescription to payment

Every billable trip passes the same stations. Errors at an early station only surface at the last one, usually as a deduction weeks after the trip.

1. 1Check the prescriptionThe trip needs a medical prescription on form Muster 4. Under section 2 (2) of the Krankentransport-Richtlinie, the patient transport directive of the Federal Joint Committee (G-BA), it should be issued before the journey. When you accept the booking, check insurer, date, destination, outbound or return leg and, for series, the period covered.
2. 2Clarify approvalTrips to outpatient treatment generally need prior approval by the insurer unless approval is deemed granted by law. For trips that require approval, the approval number later goes into the billing record.
3. 3Run the trip and have it confirmedOn the back of the Muster 4 the insured person confirms the trip, and the operator enters date, signature and its billing details. Annex 5 of the billing directives defines these fields as content of the voucher.
4. 4Collect the co-paymentThe driver collects the statutory co-payment and issues a receipt, unless an exemption applies.
5. 5Bill monthlyBilling data goes electronically to the insurer’s data receiving office, the original prescriptions with a cover sheet to the designated voucher office.
6. 6Review and paymentThe insurer checks by machine and on content, deducts where necessary and pays to the account stored under your Institutionskennzeichen.

The back of the Transportschein deserves more attention than it gets in many operations. Under annex 5 to the section 302 SGB V directives, the Muster 4 voucher includes the confirmation by the insured person, details of the exemption card and the date and signature of the transport operator. If one of these is missing, the voucher is incomplete, however flawless the trip was.

Two things must be in place before you can bill your first trip: an Institutionskennzeichen and a valid contract with the passenger’s insurer.

The Institutionskennzeichen (IK)

The IK is a nine-digit number based on section 293 SGB V. It is issued by ARGE·IK, a working group hosted by the DGUV (German Social Accident Insurance), which expressly lists taxi, hire car and patient transport companies among the applicants. According to the ARGE·IK application page you apply in writing, informally or with the official form, by post, fax or email. The application is free of charge, and according to the ARGE·IK FAQ processing usually takes 10–14 days after receipt.

Three details from that FAQ have a direct effect on your cash flow. First, address and bank account are stored under the IK, and insurers pay exactly there. Change your business account without notifying ARGE·IK in writing and you will wait for money that has long landed in the old account. Second, the IK does not replace a contract: payment goes only to contracted partners. Third, a further IK is possible for different sites, supply contracts or bank accounts, and section 5 (3) of the billing directives requires a separate one for every branch.

The contract under section 133 SGB V

Under section 133 SGB V the health insurers or their state associations agree remuneration for taxi and hire car trips with the operators; subsection 3 expressly extends this to journeys under the Passenger Transport Act (PBefG). The agreed prices are maximum prices. There is therefore no single national tariff. What you may charge per kilometre, per approach run or per waiting time depends on the federal state and the type of insurer, and AOK, substitute funds and company health funds in the same state often have different contracts.

Often the contract is a framework agreement that you join. In Baden-Württemberg, for instance, the framework agreement for seated trips requires a PBefG licence, an IK and an accession that only takes effect once the insurers confirm it. The same agreement expressly excludes wheelchair, carry-chair and stretcher trips, which have their own rules. Operators with mixed fleets may therefore bill under several contracts, each with its own position numbers.

Section 302 (1) SGB V obliges “other service providers”, which include transport operators, to transmit their services to the insurers electronically or on machine-readable media: by type, quantity and price, with date of service, the prescribing doctor’s number and the insured person’s data. The details are set by the GKV-Spitzenverband (National Association of Statutory Health Insurance Funds) in directives that contracts must observe. It publishes these directives, their technical annexes and code lists on gkv-datenaustausch.de.

This is not new. Under section 9 of the directives under section 302 (2) SGB V, machine-readable transmission has been in place since 1 January 1997. Under section 2 of the directives a bill consists of these parts:

In the data record a billing code identifies the type of provider. In the code lists of annex 3 code 46 stands for other providers of non-qualified patient transport, with taxi and hire car as the example. Individual trip items carry six-digit position numbers whose actual values are set in each contract.

The technical annexes are updated continuously, and old formats expire after a transition period. According to the overview on gkv-datenaustausch.de, version 22 of technical annex 1 applies from 1 February 2027, and data in version 21 format will only be accepted until 30 April 2027. There is also a new interface for an electronic service confirmation that can be used since 1 October 2026. Using it is expressly optional for providers and insurers. Ask your billing software vendor or billing centre whether they will support the new versions in time.

Under section 61 sentence 1 SGB V the co-payment is 10 percent of the cost, at least 5 and at most 10 euros, but never more than the trip itself costs. Section 60 SGB V ties it to the individual trip, so the outbound and return legs are two trips. The Saxon substitute funds’ model contract says the same thing: co-payment per single trip and per insured person.

Who collects is set by section 43c (1) SGB V: the provider collects the payment and offsets it against its claim on the insurer. In the bill the trip appears at its gross amount, the co-payment is deducted, and the insurer transfers the difference. Under section 61 sentence 4 SGB V the provider must give the insured person a receipt for the co-payment, and there is no fee for that effort.

• Check exemptions, do not take them on trust. Anyone who has reached the annual limit under section 62 SGB V receives a certificate from their insurer for the rest of the calendar year. Ask to see it and record the year of validity and the insurer.
• Document non-payment. If the insured person does not pay despite a separate written demand, the insurer must collect the amount under section 43c (1) sentence 2 SGB V. Without that written demand the loss stays with you.
• Do not add anything on top. Contracts usually exclude further payments by insured persons. The Baden-Württemberg agreement expressly names raising the fare by the co-payment as grounds for termination without notice.

The statute sets no national submission deadline for billing patient transport. Section 7 of the section 302 SGB V directives only contains fallback rules that apply expressly “unless contracts provide otherwise”: monthly billing per IK and payment within four weeks of receiving the complete documents. Contracts deviate from this, and they do so differently by state and type of insurer. Two examples show the range.

The table draws on the directives under section 302 (2) SGB V, the Baden-Württemberg framework agreement and the model contract for hire cars of the substitute funds in Saxony. AOK, BKK or IKK in the same state may have other contracts with other deadlines. Keep one line with these four values for every contract you have joined.

Dialysis series

For dialysis, radiotherapy and chemotherapy, one prescription for the whole period is enough in Baden-Württemberg instead of one per trip. In return the framework agreement additionally requires a fully completed and signed attendance certificate as proof that each trip took place. The three-month limit for late invoices runs from the last trip of the series, and for dialysis from the last trip of the month.

In practice a dialysis series is billed month by month, even if the prescription runs longer, and every trip needs a counter-signature from the practice or dialysis centre. Where several patients travel together to the same facility, the agreement requires shared-ride indicators and the number of passengers in the data record. It expressly names billing shared rides as individual trips as grounds for termination without notice. How long an approval for series lasts and what happens when it expires is covered in the dialysis section of the article on approval.

Section 302 (2) sentence 2 SGB V expressly allows providers to use data centres for billing. Many smaller operators do so because the data exchange has technical requirements: the billing file is encrypted, the certificate for it is tied to an IK, and the formats change with every new version of the technical annex.

ARGE·IK notes in its FAQ that when a service provider does the billing, payments are usually made under the service provider’s IK, while your own IK must still appear in the bill. Which rules apply under which contract is best checked against the clauses on billing offices in your agreement.

Choosing between the two is less a technical than an organisational decision. Both work only as well as the data coming out of daily operations. A billing centre that receives 140 Transportscheine at month end, twelve of them without the passenger’s signature, will not bill twelve trips. How to prevent such returns systematically is covered in the article on the most common reasons a proof of service is rejected.

The list follows the path of the trip. Each point can be introduced without a project.

• An IK has been applied for for every operating site, and bank account and address at ARGE·IK are up to date.
• For every type of insurer and every state you operate in there is a valid contract or accession confirmation with a current price schedule.
• For each contract, submission deadline, payment term, reduction rule and objection deadline are noted.
• Prescriptions are checked for insurer, date, destination and direction when the booking is accepted, not at month end.
• For trips requiring approval, the approval is in hand before departure, with number and period.
• Every trip has date, driver’s signature and the passenger’s confirmation on the voucher; series also have the attendance proof the contract requires.
• Co-payments get a receipt per trip, exemption certificates are recorded with their year of validity, non-payers receive a written demand.
• Shared rides are marked as such, with the number of passengers.
• Billing data and vouchers go out together, the vouchers sorted by voucher number and with a cover sheet.
• Deductions are recorded by cause and answered within the contractual deadline.

Most of these points are decided not in accounting but at the dispatch desk and in the vehicle. Whether a prescription covers the trip, whether a series runs past its end date, whether the return leg was confirmed: on the day of the trip this takes seconds, at month end it takes digging. Patient transport software comes in exactly there, bringing prescription, approval and trip together at the planning stage.